Transcription
Southwest Society of Oral& Maxillofacial Surgeonsest . October 24, 1929We are pleased that you have chosen to join the Southwest Society of Oral & Maxillofacial Surgeons!Attached please find an application for membership in the Southwest Society of Oral and MaxillofacialSurgeons. Once complete, please return it to our office along with the 35.00 application fee to thefollowing address or email:Southwest Society of Oral & Maxillofacial SurgeonsAttn: Kelly Ann Shy, MHSM, Executive Director4499 Medical Drive, Suite #190San Antonio, Texas 78229Upon receipt of the application, this information will be forwarded to our Membership Committee forverification of credentials. Following such, your application for membership will be presented to thegeneral membership for vote at the next membership meeting.The Southwest Society hosts a formal meeting one a year during the Southwest Society of Oral &Maxillofacial Surgeons Annual Meeting held in the Spring of each year. The deadline for applications isMarch 1st.Should you have any questions regarding the application process, please contact our office viatelephone: 210-614-3915 or via email: kellyannshy@alamoOMS.com.
Southwest Society of Oral andMaxillofacial SurgeonsEst. October 24, 1929CREDIT CARD PAYMENT AUTHORIZATION FORMMember Name:AddressPhone NumberPayment To: SWSOMSMasterCard/Visa/Discover/American ExpressCard #Expiration Date:CVV Code:/Billing Zip Code:Cardholder Name:Signature:Date:PLEASE FAX YOUR COMPLETED CREDIT CARD AUTHORIZATION TO:210-614-5234-OR- EMAIL YOUR COMPLETED CREDIT CARD AUTHORIZATION TO:kellyannshy@alamoOMS.com or laguilar@alamoOMS.com**please note that your email transmission, unless encrypted, is not secure. Should you wish to scan and password protect thisinformation if encryption is not available, please use SWSOMS12 as the password for this document and our office will be ableto open and retrieve this information.**
Southwest Society of Oral& Maxillofacial Surgeonsest . October 24, 1929Application for uffixNoUS Citizen YesSuite #StreetCityStateOffice PhoneZipFacsimileWebsiteEmailPreferred Method of Contact: (Please Circle) Office Address / Mailing Address / EmailMailing Address if Different From Office Address:Date of Birth: / /MonthDateSpouse ersityDate of GraduationDegreeName of SchoolDate of GraduationDegreeName of SchoolDate of GraduationDegreeResidency Program:Dates of EntryDirector / ContactName of SchoolCompletionCityStatePhone NumberAdditional Education:Military Experience (Highest Rank held, professional experience and inclusive dates):
Applicant:Page 2 of 3LastMiddleFirstPractice limited exclusively to Oral and Maxillofacial Surgery? YesNoYears in Practice:State of Dental LicensureDateState of Medical LicensureDateAdditional Licensure & StateDateAdditional Licensure & StateDateAre you a member of the American Association of Oral and Maxillofacial Surgeons?YesNoAre you a diplomate of the American Board of Oral and Maxillofacial Surgey?YesNoIf "No" to question 10, are you presently Board eligible?YesNoIf "No" to questions 10 and 11, have you ever been Board eligible?YesNoAre you engaged in research or teaching of Oral and Maxillofacial Surgery in a dental or medical institution?YesList of Dental/Medical Societies to which you belong:DateDateDateDateNoPresent Hospital Affiliations:HospitalCityStateStaff CategoryHospitalCityStateStaff CategoryHospitalCityStateStaff CategoryHospitalCityStateStaff CategoryEndorsement from Active or Life members of Southwest Society of Oral and Maxillofacial Surgeons:NameNameAddressAddressCity, State and Zip CodeCity, State and Zip CodeSignature of SponsorSignature of Sponsor* Please list on a separate sheet any contributions to dental/medical literature, essays presented and research activities* Please attach letter of successful completion of formal trainin gfrom the program director (required).* Please include payment of 35.00 of the membership application fee made payable to: SWSOMSApplicant Signature:Date:
Applicant:Page 3 of 3LastFirstMiddleFor Membership Committee ActionApplication Received:Letter verifying successful completion of formal training from the program director receivedAction by Committee:AcceptedRejectedDeferreredCommittee Chair SignatureDateRejectedDeferreredExecutive Director SignatureDateAction by Society:Accepted
The Southwest Society hosts a formal meeting one a year during the Southwest Society Oral & of Maxillofacial Surgeons Annual Meeting held in the Spring of each year. The deadline for applications is March 1. st. Should you have any questions regarding the application process, please contact our office via . telephone: 210-614-3915 or via email:
